Alba M Barahona

The Enrollment Eligibility Specialist is responsible for reviewing and assessing an individual's financial and personal information to determine if they qualify for government assistance programs, such as welfare, Medicare, ACA- Pennie, by verifying their details against program guidelines and making eligibility decisions based on established criteria; often involving client interviews and data analysis to ensure accurate compliance with regulations. Responsible for the patient insurance verification process to ensure proper payment from insurers, provider assistance to reduce out-of-pocket expenses related to all services performed in a clinical setting, Health services, Assess and enroll patient in other assistance programs for which they qualify, Interpret and apply sliding fee scale and ensure that documentation related to the sliding fee scale is accurately and consistently captured in the electronic medical record. Enroll eligible patients into The Gloria Gates Care programs, intake and alerts patients to recertify annually, Coordinate all referrals from Trillium providers, ensure patients/clients are scheduled for their services, and track open referrals for proper follow through of appointments. Inform and advises on policies and procedures related to uninsured patients. Ensure cross-departmental support and collaboration.

Job Responsibility:

• Out-Inbound Calls 60 Per day Minimum

• Perform insurance verification checks to enroll new patients to GGcares in order to maintain compliance.

• Ensure “primary” and “secondary” valid insurance designations are accurately

represented in electronic health record

• Contact patient when insurance checks result in invalid status and establish strategy for addressing gaps (referrals to services, possibly rescheduling patient until insurance matters have been resolved, etc.)

• Ensure patient demographics are maintained with updated information.

• Assess patients for eligibility for Medicaid, Medicare, and private insurance available through ACA marketplace and assist patients in applying for assistance.

• Assist patients in applying for insurance assistance during ACA open enrollment.

• Populate “know your coverage” scorecard and educate patient on information in scorecard.

• Enroll patients into GGcares program at intake, conduct 6 month and annual recertification. At each recertification, determine the patient’s level

Sliding Fee Scale and Cap on Charges and educate patients about these benefits.

• Manage enrollment paperwork, primary insurance, proof of residency, and proof of income.

• Monitor patient progress toward GGcares Cap on Charges and adjust a patient’s cap in coordination with Billing and document it consistently in the electronic medical record as needed.

• Educate patient on GGcares “benefits” and services.

• Assign the patient to the appropriate specialty provider or facility based on the patient’s current medical needs as defined by the primary care provider

• Provide all the required medical history information regarding the patient to the

specialty provider or facility.

• Coordinate with insurance carriers and specialty practices to obtain prior authorizations, pre certifications and referrals on applicable plans which include HMO, PPO and POS health plans and documents all benefit information into the patients’ electronic medical record.

• Enter all the referral information into the electronic medical record system.

• Contact patient, specialty provider or facility to reschedule missed appointments for patients as applicable.

• Keep track of patient/client referrals in the system and follow up with clients who have missed referral appointments.

• Responsible for educating patients and prospective patients on sliding fee scales.

• Follow all established policies & processes related to uninsured patients.

• Communicate directly with patients who submit billing & reimbursement questions through the patient portal.

• Collaborate with Front Office Teams to coordinate enrollment and eligibility

follow-up as needed.

• Ensured compliance with all applicable laws and regulations governing benefit programs.
• Communicated regularly with clients regarding their application status or changes in policies or procedures that may affect them.
• Participated in community events related to social services outreach initiatives.
• Assisted clients with completing forms required for processing applications.
• Maintained comprehensive knowledge of program regulations, policies, and procedures.
• Developed strategies to improve efficiency in the processing of applications and customer service delivery.
• Analyzed financial information provided by applicants to verify income levels.
• Explained eligibility details and affordability options to patients with kindness and respect.
• Responded to client inquiries and concerns and escalated complex problems to department supervisors.
• Entered client information and files into databases for further review and tracking.
• Managed intake of new claims and performed routine follow-ups.
• Granted, modified, denied, or terminated assistance based on key information and eligibility determination.
• Maintained positive working relationship with fellow staff and management.
• Maintained confidential patient documentation to prevent data compromise and comply with HIPAA regulations.

Optum Field services is an industry-leading provider of complex claims and revenue cycle management services. We specialize in Motor Vehicle Accidents, Worker’s Compensation, Complex Denials, Out-of-State Medicaid, Aged AR, and Eligibility and Enrollment Services.

• Managed department high call volume and coordinated department schedules to

maximize coverage during peak hours.

• Oversaw staff development through in-depth trainings, workshops, seminars and

• Conducted performance reviews for team members.
• Managed vendor relationships by negotiating contracts and ensuring timely delivery of goods and services.
• Established processes to ensure efficient workflow throughout the organization.
• Provided leadership during times of organizational change or crisis situations.
• Assessed team member's skillsets and assigned tasks accordingly for optimal efficiency.
• Developed and implemented strategies to increase customer satisfaction and loyalty.
• Maintained up-to-date records of employee attendance, payroll information, vacation requests.
• Coached, mentored and trained team members in order to improve their job performance.
• Created monthly reports for senior management summarizing operational performance metrics.
• Ensured compliance with all applicable laws, regulations, industry standards.
• Monitored budgets and expenditures to ensure cost-effectiveness while maintaining quality standards.
• Conducted regular meetings with staff to discuss progress and identify areas of improvement.
• Enforced customer service standards and resolved customer problems to uphold quality service.
• Managed annual budgeting and forecasting, optimizing resource allocation.
• Established and monitored KPIs to evaluate performance and identify areas for improvement.
• Assigned tasks to associates to fit skill levels and maximize team performance.
• Resolved customer complaints and issues promptly, maintaining a positive brand image.
• Streamlined communication channels, improving information flow and decision-making speed.
• Led team meetings and one-on-one coaching sessions to continuously improve performance.
• Oversaw daily operations, maintaining efficiency and quality standards.
• Monitored staff performance and addressed issues.
• Recruited and trained new employees to meet job requirements.
• Provided leadership, insight and mentoring to newly hired employees to supply knowledge of various company programs.
• Evaluated individual and team business performance and identified opportunities for improvement.
• Planned and delivered training sessions to improve employee effectiveness and address areas of weakness.
• Analyzed business performance data and forecasted business results for upper management.
• Mediated conflicts between employees and facilitated effective resolutions to disputes.
• Created and managed budgets for travel, training, and team-building activities.
• other learning opportunities.
• Referred clients to appropriate team members, community agencies and
• organizations to meet treatment needs.

• Developed and created programs and monitored effectiveness against individual

participant needs.

• Developed monthly schedules and assignments for staff.

• Recruited, interviewed and hired staff members offering exceptional talent and

brought great skills to team.

• Led process improvement and problem-solving efforts to create standard procedures and escalation policy for customer support team.

• Primary ownership of detailed models to forecast, measure, and validate

performance improvements for markets.

• Support operations Teams in understanding how their actions will impact the measured results and financial outcomes.

• Build solid partnership with Optum and UHC teams through leading monthly performance reviews and ad hoc conversations.

• Implement process and procedures for measurement and validation of membership and overall finance performance metrics.

• Conduct general Ledger and claims research/analysis for month end close to identify variances.

• Establish and implement financial performance metric audits and testing to ensure results match forecast projections.

• Timecard management and approvals

• Scheduled interviews for potential candidates and conducted reference checks prior to hire.
• Analyzed customer feedback data to develop action plans for improving services offered.
• Resolved conflicts between employees by providing guidance on company policies and procedures.
• Remained calm and professional in stressful circumstances and effectively diffused tense situations.

The Healthcare Representative is responsible for assisting hospital patients with the completion of the application process for any applicable governmental medical assistance programs which could include Medicaid, Disability, or Charity programs, also assist with the process and billing of the MVA and WC claims.

The Eligibility Specialist not only acts as an advocate for the patient, but also serves as a liaison to other Team members and to client hospital and government agency staff in a collaborative effort to facilitate eligibility coverage for incurred medical expenses. Assist patients or family at the bedside and start Health care application basic on the eligibility, follow up on accounts, set hospital accounts with the correct insurance and financial class, follow up approvals, assist with all the inbound and outbound calls from patients inquiring for medical

assistance or payment plans, select at the beginning of the shift all referrals that are required to be seeing after checking Medicaid or other programs that may be covered and are not active for date of service, obtained all paper work necessary to finalized process, create a daily report from all patients and accounts set up or claim submitted.

Job Responsibility:

• Work effectively with hospital employees and patients.

• High Volume Inbound/Outbound Calls to review for medical benefits.

• Interviewing clients in a hospital setting onsite 1/1 or via phone and/or home

visits to assist the clients in obtaining maximum benefit coverage.

• Completion of applications for state and federal programs (including Health Exchange/Marketplace programs), reviewing medical records and taking all necessary action to expedite benefit approval.

• Achieve and maintain certification designation as “Certified Application Counselor” if applicable.

• Adherence to company and legal standards regarding Protected Health

Information (PHI), Personal Identifiable Information (PII) and Personnel

Transaction Identifier (PTI).

• Maintain ongoing communication with government agencies regarding the status

of claims.

• Provide updates and assistance to hospital personnel and other Change Healthcare staff as needed.

• Maintain documentation of status of claims and client contract on Change Healthcare and/or hospital computer systems.

• Making a determination to take a Federal, State or Local program application based upon medical definition of disability as it relates to body systems and to functions of daily living, and information contained in medical records.

• Submit electronic and hard copy billing and conduct follow up with third party carriers for insurance claims.

• Investigate and coordinate insurance benefits for insurance claims across multiple service lines.

• Obtain claim status via the telephone, internet, and/or fax.

• Review and understand eligibility of benefits.

• Resolve accounts as quickly and accurately as possible, obtaining maximum reimbursement, and perform investigative and follow up activities in a fast-paced environment.

• Conduct research, contact patients, and the local affiliates to include VA, Hospitals, and insurance carriers.

• Handle incoming and outgoing mail, scanning, and indexing documents and handling any other tasks that are assigned.

• Research and verify insurance billing adjustment identification to ensure proper

account resolution and act when necessary.

• Identify contractual and administrative adjustments.

• Work independently or as a member of a team to accomplish goals.

• Demonstrate excellent customer service, communication skills, creativity, patience, and flexibility.

• Follow established organization guidelines to perform job functions while staying abreast to changes in policies.

• Correspond with hospital contacts professionally using appropriate language

while following the specific facility and department protocol.

• Uphold confidentiality regarding protected health information and adhere to

• HIPPA regulation.

• Interact with all levels of staff.

• Cross train in multiple areas and perform all other duties as assigned by management.

• Developed health education materials for patients and their families.
• Actively participated in team meetings focused on improving patient care outcomes.
• Facilitated communication between patients and physicians regarding treatment plans and follow-up care instructions.

The Eligibility Specialist is responsible for assisting hospital patients with the completion of the application process for any applicable governmental medical assistance programs which could include Medicaid, Disability, or Charity programs. The Eligibility Specialist not only acts as an advocate for the patient, but also serves as a liaison to other Team members and to client hospital and government agency staff in a collaborative effort to facilitate eligibility coverage for incurred medical expenses. Assist patients or family at the bedside and start

Health care application basic on the eligibility, follow up on accounts, set hospital accounts with the correct insurance and financial class, follow up approvals, assist with all the inbound and outbound calls from patients inquiring for medical

assistance or payment plans, select at the beginning of the shift all referrals that are required to be seeing after checking Medicaid or other programs that may be covered and are not active for date of service, obtained all paper work necessary to finalized process, create a daily report from all patients and accounts set up or

claim submitted.

• Work effectively with hospital employees and patients.

• High Volume Inbound/Outbound Calls to review for medical benefits.

• Interviewing clients in a hospital setting onsite 1/1 or via phone and/or

home visits to assist the clients in obtaining maximum benefit coverage.

• Completion of applications for state and federal programs (including

Health Exchange/Marketplace programs), reviewing medical records and

taking all necessary action to expedite benefit approval.

• Achieve and maintain certification designation as “Certified Application Counselor” if applicable.

• Adherence to company and legal standards regarding Protected Health

Information (PHI), Personal Identifiable Information (PII) and Personnel

Transaction Identifier (PTI).

• Maintain ongoing communication with government agencies regarding

the status of claims.

• Provide updates and assistance to hospital personnel and other Change Healthcare staff as needed.

• Maintain documentation of status of claims and client contract on Change Healthcare and/or hospital computer systems.

• Making a determination to take a Federal, State or Local program application based upon medical definition of disability as it relates to body

systems and to functions of daily living, and information contained in medical records.

• Attended to patient and family's immediate needs and concerns by acknowledging

and providing required attention.

• Assisted with feeding and monitored intake to help patients achieve nutritional

objectives.

• Monitored, tracked and conveyed important patient information to healthcare staff

to help optimize treatment planning and care delivery.

• Recorded temperature, blood pressure, pulse, or respiration rate as directed by

medical or nursing staff.EDUCATION LANGUAGES .

• Wiped down equipment with proper cleaning products after each patient transport

to reduce instances of infection.

• Answered call lights and supported patient comfort and safety by adjusting bed

rails and equipment.

• Collected and transported specimens to prepare for lab testing.